1. Vaccination against pertussis (whooping cough) for pregnant women An update for healthcare professionals May 2014

2. Key Message Infant cases of pertussis have been dramatically reduced by the introduction of the temporary maternal immunisation programme. However, the disease continues to circulate in older age groups Therefore it is important for all health professionals to encourage vaccination in pregnant women from 28 weeks, at the earliest opportunity © NHS Scotland/Crown Copyright 2Vaccination against pertussis for pregnant women

3. Aims of Resource To support staff involved in discussing vaccination against pertussis with pregnant women by providing evidence based information To raise awareness of current pertussis epidemiology and the impact of pertussis on young infants To promote uptake of vaccination against pertussis through increasing awareness amongst healthcare professionals 3 © NHS Scotland/Crown Copyright 3Vaccination against pertussis for pregnant women

4. Learning Outcomes After completing this resource immunisers will be able to: Understand their role in raising the issue of vaccination against pertussis with all women in the antenatal period and providing women with evidence based information about this vaccination Describe the aetiology and epidemiology of pertussis Understand how pertussis is transmitted and the severity of it in young infants Discuss the important role of vaccination against pertussis during pregnancy for young infants Be aware of sources of additional information 4Vaccination against pertussis for pregnant women

5. Contents 1.What is pertussis? 2.Why vaccinate pregnant women against pertussis? 3.Vaccination against pertussis and the use of Boostrix® 4.The role of the immuniser 5.Resources 5Vaccination against pertussis for pregnant women

6. What is pertussis? 6Vaccination against pertussis for pregnant women

7. What is pertussis? Pertussis is an acute bacterial infection caused by Bordetella pertussis It is highly contagious and can be passed from person to person through droplets from the nose and throat of infected individuals when coughing and sneezing Infants and young children have the highest rates of complications Infants are the most vulnerable group and almost all deaths from pertussis occur in this age group with most <3 months of age Photo courtesy of CDC 7Vaccination against pertussis for pregnant women

8. What is pertussis? (cont’d) Incubation period The incubation period is on average 7- 10 days (range 5-21 days) Infectious period Patients with pertussis are most infectious in the initial catarrhal stage and during the first three weeks after the onset of cough Photo courtesy of CDC 8Vaccination against pertussis for pregnant women

9. Clinical presentation of pertussis Initial stage Early symptoms are: similar to those of a cold can last for one to two weeks before becoming more severe Second or Paroxysmal Stage Characteristic symptoms: Intense bouts of coughing sometimes referred to as ‘paroxysms’ of coughing a ‘whoop’ sound with each sharp intake of breath after coughing (may not occur in infants) Vomiting after coughing © NHS Scotland/Crown Copyright 9Vaccination against pertussis for pregnant women

10. Clinical presentation of pertussis (cont’d) Convalescent stage Symptoms: Slowly become less severe Generally last 2-6 weeks but can persist for months © NHS Scotland/Crown Copyright 10Vaccination against pertussis for pregnant women

11. Clinical presentation of pertussis in infants and young children Infants may not make the ‘whoop’ sound after coughing, but they may start gagging or gasping and may temporarily stop breathing Young children may also seem to choke or become cyanosed when they have a bout of coughing Photo courtesy of CDC 11Vaccination against pertussis for pregnant women

12. Complications in infants and young children Infants and young children are usually most severely affected and more likely to develop severe complications such as: Pneumonia Temporary pauses in breathing as a result of severe difficulty with breathing Weight loss due to excessive vomiting Seizures or brain damage Encephalitis (an acute inflammation of the brain) In severe cases pertussis can be fatal in infants 12Vaccination against pertussis for pregnant women

13. Complications of pertussis in older children & adults Complications in older children and adults are usually much less serious than those in infants and young children. These may include: nosebleeds and burst blood vessels in the whites of the eye from intense bouts of coughing bruised ribs as a result of intense coughing hernia due to intense coughing a swollen face ulcers on the tongue and mouth ear infections such as otitis media 13Vaccination against pertussis for pregnant women

14. Why vaccinate pregnant women against pertussis ? 14Vaccination against pertussis for pregnant women

15. What did the epidemiology of pertussis in 2012 tell us? Incidence of confirmed pertussis cases at all ages, England & Wales 15Vaccination against pertussis for pregnant women

16. Age distribution of laboratory confirmed pertussis cases and rate per 100,000 England and Wales 2012 16Vaccination against pertussis in pregnancy

17. Confirmed cases in infants under 1 year, by week of age at onset* (2011-end August 2012) England and Wales * Where provided; specimen date used when onset not available Dose 1 Dose 2 Dose 3 17Vaccination against pertussis for pregnant women

18. Reconciled deaths from pertussis in infants (England only) Sources: lab confirmed cases, certified deaths, Hospital episode statistics, GP registration details

19. How can we help prevent pertussis? The childhood vaccination programme The main strategy for reducing the impact (morbidity and mortality) from pertussis is the current childhood vaccination programme What does this current vaccination programme look like? Pertussis is part of the infant vaccination programme 5-in-1 vaccine (DTaP/IPV/Hib) is offered to infants at two, three and four months of age. This protects against pertussis, diphtheria, tetanus, polio and Haemophilus influenzae type b A booster dose of pertussis containing vaccine is given to children from about three years and four months of age 19 Vaccination against pertussis for pregnant women

20. Immunity against pertussis Vaccination against pertussis does not give life-long immunity Individuals who have previously had pertussis can become re-infected and spread infection to others This spread of infection is important, particularly in children too young to be vaccinated 20Vaccination against pertussis for pregnant women

21. How can we protect children too young to be vaccinated against pertussis? One dose of pertussis containing vaccine from 28-38 weeks, with the ideal time being 28-32 weeks gestation The aim is to boost antibodies in vaccinated women in late pregnancy so that pertussis antibodies are passed from mother to baby This is considered the best way to provide passive protection to infants in the first weeks of life and offers women a safe way to protect their baby against this serious disease On the advice of the JCVI, the programme will continue into 2014 © NHS /Crown Copyright 21Vaccination against pertussis for pregnant women In October 2012, the Department of Health recommended that pregnant women receive

22. Why vaccinate pregnant women? The immunity acquired by vaccination will be passed across the placenta by antibodies and should help protect the baby in the first few weeks of life, when they are most at risk of serious complications if they become infected with pertussis © NHS Scotland/Crown Copyright 22Vaccination against pertussis for pregnant women

23. Why vaccinate pregnant women against pertussis (cont’d)? Helps protect the baby Babies born to mothers vaccinated at the recommended time during pregnancy should have higher levels of antibodies than those born to unvaccinated mothers, which should help protect the infant until they start receiving their own immunisations Helps protect the mother Reduces the risk of the mother catching pertussis and passing it on to the young infant © NHS Scotland/Crown Copyright 23Vaccination against pertussis for pregnant women

24. Is the pertussis vaccination in pregnancy programme proving effective? 24Vaccination against pertussis for pregnant women

25. Collected pertussis vaccine uptake in pregnant women Oct 2012- March 2014 (England only) Source: Public Health England http://www.hpa.org.uk/hpr/infections/immunisation.htm 25Vaccination against pertussis for pregnant women

26. Annual age specific laboratory confirmed pertussis incidence rates 1998 – 2013: England 26Vaccination against pertussis for pregnant women

27. Reconciled deaths from pertussis in infants England only Sources: lab confirmed cases, certified deaths, Hospital episode statistics, GP registration details *to end April 27Vaccination against pertussis for pregnant women

28. Vaccination against pertussis (whooping cough) - the use of Boostrix-IPV® 28Vaccination against pertussis for pregnant women

29. The recommended vaccine: Boostrix-IPV® Brand name: Boostrix-IPV® Generic Name: Diphtheria, Tetanus, Pertussis (acellular, component) and Poliomyelitis (inactivated vaccine) adsorbed (dTaP/IPV) Marketed by GlaxoSmithkline UK Inactivated (N.B. the vaccine cannot cause pertussis) Presented as a prefilled syringe 29Vaccination against pertussis for pregnant women Image courtesy of GlaxoSmithKline UK

30. 30 All staff should be familiar with the BOOSTRIX-IPV packaging X Ensure that all those administering the vaccine are familiar with the product Please ensure that you use the correct vaccine and that you accurately record the brand and batch number Images courtesy of GlaxoSmithKline UK Vaccination against pertussis for pregnant women

31. Composition of Boostrix-IPV® Diphtheria Toxoid not less than 2IU Tetanus Toxoid not less than 20IU Pertussis antigens Pertussis Toxoid 8 micrograms Filamentous Haemagglutinin 8 microgram Pertactin 2.5 micrograms Poliovirus (inactivated) Type 1 40 D antigen units Type 2 8 D antigen units Type 3 32 antigen units 31Vaccination against pertussis for pregnant women

32. Composition of Boostrix-IPV® (Cont’d) Excipients Medium 199 Sodium Chloride Water for injections Adjuvant Aluminium hydroxide 0.3mg Aluminium phosphate (hydrated) 0.2mg Residual substances Neomycin Polymyxin B 32Vaccination against pertussis for pregnant women

33. Administration of Boostrix-IPV® Licensing: The Green Book states that: “Pertussis-containing vaccines may be given to pregnant women when protection is required without delay. There is no evidence of risk from vaccinating pregnant women or those who are breast-feeding with inactivated viral or bacterial vaccines or toxoids (Plotkin & Orenstein 2004)” The vaccine marketing authorisation holder’s Summary of Product Characteristics (SPC) for Boostrix-IPV® states that the vaccine can be used in pregnancy when clearly needed. In a study of 20,000 women vaccinated with dTaP/IPV during pregnancy, the MHRA found no evidence of risk The advice from JCVI to use pertussis containing inactivated vaccines should be followed. There is no evidence of risk to pregnancy or the infant with inactivated vaccines such as Boostrix-IPV® 33Vaccination against pertussis for pregnant women

34. Administration of Boostrix-IPV® (Cont’d) The vaccine comes as pre-filled suspension that must be shaken before use to form a white suspension Given by intramuscular injection into the deltoid Can be given at the same time as other vaccines such as influenza May only be administered: Against a prescription written manually or electronically by a registered medical practitioner or other authorised prescriber Against a Patient Specific Direction Against a Patient Group Direction 34Vaccination against pertussis for pregnant women

35. Contraindications and Precautions Contraindications A confirmed anaphylactic reaction to a previous dose of diphtheria, tetanus, pertussis or poliomyelitis containing vaccine A confirmed anaphylactic reaction to any component of the vaccine, including neomycin and/or polymyxin Precautions Acute illness- defer until recovered Recent immunisation against pertussis, diphtheria, tetanus and or polio- ensure an interval of 4 weeks Current neurological deterioration or encephalopathy of unknown origin within seven days of previous immunisation with pertussis- containing vaccine- follow advice in the Green Book 35Vaccination against pertussis for pregnant women

36. Possible adverse reactions Most Common Erythema (redness), pain, swelling at the injection site Less Common Pyrexia (>37.5C), haematoma, induration, pruritus and warmth at the injection site Uncommon Swelling of vaccinated limb, pyrexia (>39.5), chills, pain 36Vaccination against pertussis for pregnant women

37. Reporting suspected adverse reactions Yellow card scheme Voluntary reporting system for suspected adverse reaction to medicines/vaccines Success depends on early, complete and accurate reporting Report even if uncertain about whether vaccine caused condition http://mhra.gov.uk/yellowcard See chapter 8 of Green Book for details 37Vaccination against pertussis for pregnant women

38. Recommendations Women who become pregnant again while the programme is in place should be offered immunisation during each pregnancy to maximise transplacental transfer of antibody One dose of Boostrix-IPV® is recommended for women carrying twins or multiple pregnancies Vaccination may be offered to new mothers who have never previously been vaccinated against pertussis, up to when their child receives their first vaccination. A single dose of Boostrix-IPV® is recommended in these circumstances New mothers who have never previously been vaccinated against pertussis are unlikely to have been fully vaccinated against diphtheria, tetanus and polio and should be assessed as to the need for further immunisations with Td/IPV vaccine 38Vaccination against pertussis for pregnant women

39. Data management Health professionals are encouraged to accurately record the brand and batch number of the vaccine in relevant data systems following the administration The delivery date of the baby should also be recorded in the mother’s medical records This information is essential to allow an assessment of vaccine uptake, safety and to inform any future public health actions, if required Vaccination against pertussis should be recorded in the women’s medical/maternity records and recorded in the relevant data system Vaccine uptake of Boostrix-IPV® for pregnant women will be monitored with a monthly data collection though ImmForm 39Vaccination against pertussis for pregnant women

40. Providing longer term protection against pertussis The protection the infant acquires from the mother by the transfer of antibodies across the placenta is short term It is very important that parents ensure their infants start their immunisation schedule at the recommended 8 weeks and complete all three doses to receive long lasting protection Parents should ensure older brothers and/or sisters are up to date with their immunisations © NHS Scotland/Crown Copyright 40Vaccination against pertussis for pregnant women

41. The healthcare professionals’ key role To provide clear, concise and accurate information to every pregnant woman regarding vaccination against pertussis Every effort should be made by medical practitioners, midwives and others to maximise the uptake of pertussis- containing vaccine 41Vaccination against pertussis for pregnant women

42. Resources DH, PHE and NHS England Tripartite Letter (2013) Continuation of temporary programme of pertussis vaccination of pregnant women [link]link NHS Choices (2013). Whooping cough vaccination in pregnancy programme [link]link] Public Health England (2013). Immunisation against infectious diseases (Green Book). [link]link] Department of Health. Pertussis vaccine in pregnancy programme. [link]link] Public Health England (2014) Vaccination against pertussis for pregnant women: an update for health professionals training slide and advice for health professionals document [link]link] 42Vaccination against pertussis for pregnant women

43. Key Message Infant cases of pertussis have been dramatically reduced by the introduction of the temporary maternal immunisation programme. However, the disease continues to circulate in older age groups It is important for all health professionals to encourage vaccination in pregnant women from 28 weeks, at the earliest opportunity © NHS Scotland/Crown Copyright 43Vaccination against pertussis for pregnant women

44. Acknowledgement This resource was developed by NHS Education for Scotland as a national training template to support the temporary maternal pertussis vaccination programme. Their permission to adapt it for use in England is gratefully acknowledged. Adaption for use in England undertaken by the Immunisation, Hepatitis and Blood Safety Department Public Health England-Colindale 44Vaccination against pertussis for pregnant women